Crash of a Mitsubishi MU-2B-30 Marquise in Melbourne: 1 killed

Date & Time: Dec 21, 1994 at 0324 LT
Type of aircraft:
Registration:
VH-IAM
Flight Type:
Survivors:
No
Schedule:
Sydney – Melbourne
MSN:
517
YOM:
1970
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
5000
Captain / Total hours on type:
150.00
Circumstances:
The aircraft departed Sydney for Melbourne International airport at 0130 on 21 December 1994. En-route cruise was conducted at flight level 140. Melbourne Automatic Terminal Information Service (ATIS) indicated a cloud base of 200 feet for the aircraft's arrival and runway 27 with ILS approaches, was in use. Air Traffic Control advised the pilot of VH-UZB, another company MU2 that was also en-route from Sydney to Melbourne, and the pilot of VH-IAM while approaching the Melbourne area, that the cloud base was at the ILS minimum and that the previous two aircraft landed off their approaches. VH-UZB was slightly ahead of VH-IAM and made a 27 ILS approach and landed. In response to an inquiry from the Tower controller the pilot of VH-UZB then advised that the visibility below the cloud base was 'not too bad'. This information was relayed by the Tower controller to the pilot of VH-IAM, who was also making a 27 ILS approach about five minutes after VH-UZB. The pilot acknowledged receipt of the information and was given a landing clearance at 0322. At 0324 the Approach controller contacted the Tower controller, who had been communicating with the aircraft on a different frequency, and advised that the aircraft had faded from his radar screen. Transmissions to VH-IAM remained unanswered and search-and-rescue procedures commenced. Nothing could be seen of the aircraft from the tower. A ground search was commenced but was hampered by the darkness and reduced visibility. The terrain to the east of runway 27 threshold, in Gellibrand Hill Park, was rough, undulating and timbered. At 0407 the wreckage was found by a police officer. Due to the darkness and poor visibility the policeman could not accurately establish his position. It took approximately another 15-20 minutes before a fire vehicle could reach the scene of the burning aircraft. The fire was then extinguished.
Probable cause:
The following factors were reported:
1. The company's training system did not detect deficiencies in the pilot's instrument flying skills.
2. The cloud base was low at the time of the accident and dark night conditions prevailed.
3. The pilot persisted with an unstabilised approach.
4. The pilot descended, probably inadvertently, below the approach minimum altitude.
5. The pilot may have been suffering from fatigue.
Final Report:

Crash of a De Havilland DHC-2 Beaver in Cooplacurripa: 1 killed

Date & Time: Dec 19, 1994 at 1940 LT
Type of aircraft:
Operator:
Registration:
VH-BSC
Flight Phase:
Survivors:
No
Schedule:
Cooplacurripa - Cooplacurripa
MSN:
1617
YOM:
1966
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
800
Captain / Total hours on type:
350.00
Circumstances:
The aircraft was operating from an agricultural airstrip 600 feet above mean sea level, spreading superphosphate over moderately steep undulating terrain. The duration of each flight was 6-7 minutes. The accident flight was the seventh and probably intended to be the last for the day. A witness, who was situated under the flight path, reported that the aircraft was tracking east-north-east in what appeared to be normal flight. Her attention was distracted for a few moments and when she next saw the aircraft it was in a near vertical dive with the upper surface of the wings facing her. The aircraft then struck the hillside and burst into flames. Examination of the wreckage did not reveal any pre-existing defect which may have contributed to the accident. Impact marks on the propeller indicated that the engine was operating at impact. The superphosphate load remained in the hopper and the emergency dump system actuating lever was in the closed position. Inspection indicated that the dump system was serviceable prior to impact. Calculations indicated that at the time of the accident the aircraft, although heavily loaded, was operating within the flight manual maximum weight limitation. A light north-easterly wind was observed at the airstrip. However, at the accident site, which was about 250 feet higher, the wind was a moderate west-north-westerly. Sky conditions were clear with a visibility of 30 km. The aircraft probably experienced windshear and turbulence as it encountered a quartering tailwind approaching the ridgeline. The result would have been a reduction in climb performance and it is likely that the pilot attempted to turn the aircraft away from the rising terrain. During the turn it appears that the aircraft stalled and that the pilot was unable to regain control before it struck the ground.
Probable cause:
The reason the pilot did not dump the load when the climb performance was reduced could not be determined.
The following factors were determined to have contributed to the accident:
1. Shifting wind conditions conducive to windshear and turbulence were present in the area.
2. The aircraft was climbing at near to maximum allowable weight.
3. Control of the aircraft was lost with insufficient height available to effect a recovery.
Final Report:

Crash of a Rockwell Grand Commander 680F near Cloncurry: 2 killed

Date & Time: Nov 9, 1994 at 1015 LT
Operator:
Registration:
VH-SPP
Flight Phase:
Survivors:
No
Schedule:
Cloncurry - Cloncurry
MSN:
680-1128-74
YOM:
1961
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
11400
Captain / Total hours on type:
710.00
Aircraft flight hours:
7546
Circumstances:
The aircraft was engaged in aero-magnetic survey operations in an area which extended from approximately 40–130 km south of Cloncurry. The task involved flying a series of north-south tie lines spaced 2 km apart at a height above ground of 80 m and a speed of 140 kts. At this speed, each tie line occupied about 20 minutes of flight time. The flight was planned to depart Cloncurry at 0700–0730 EST and was to return by 1230 to prepare data collected during the flight for transfer to the company’s head office. An employee of the operating company saw the crew (pilot and equipment operator) preparing to depart the motel for the airport at about 0500. No person has been found who saw the crew at the aerodrome or who saw or heard the aircraft depart. At about 1000, three witnesses at a mining site in the southern section of the survey area saw a twin-engine aircraft at low level heading in a northerly direction. One of these witnesses, about 1.5 hours later, saw what he believed was the same aircraft flying in an easterly direction about 1 km from his position. Between 1000 and 1030, two witnesses at a mine site some 9 km north of the survey area (and about 5 km west of the accident site) heard an aircraft flying in a north-south direction, apparently at low level. On becoming aware that the aircraft had not returned to Cloncurry by 1230, a company employee at Cloncurry initiated various checks at Cloncurry and other aerodromes in the area, with Brisbane Flight Service, and with the company’s head office later in the afternoon. At about 2030, the employee advised the company chief pilot that the aircraft was overdue. The chief pilot contacted the Civil Aviation Authority Search and Rescue organisation at about 2045 and search-and-rescue action was initiated. The burnt-out wreckage of the aircraft was found early the following morning approximately 9 km north of the survey area.
Probable cause:
For reason(s) which could not be conclusively established, the pilot shut off the fuel supply to the left engine and feathered the left propeller. For reason(s) which could not be conclusively established, the pilot lost control of the aircraft.
Final Report:

Crash of a Douglas C-47A-20-DK off Sydney

Date & Time: Apr 24, 1994 at 0910 LT
Registration:
VH-EDC
Flight Phase:
Survivors:
Yes
Schedule:
Sydney - Norfolk Island - Lord Howe Island
MSN:
12874
YOM:
1944
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
21
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
9186
Captain / Total hours on type:
927.00
Copilot / Total flying hours:
500
Copilot / Total hours on type:
250
Aircraft flight hours:
40195
Circumstances:
This accident involved a DC-3 aircraft which was owned and operated by South Pacific Airmotive Pty Ltd, who were based at Camden, NSW. It was flown on commercial operations under an Air Operators Certificate held by Groupair, who were based at Moorabbin, Vic. The aircraft had been chartered to convey college students and their band equipment from Sydney to Norfolk Island to participate in Anzac Day celebrations on the island. A flight plan, submitted by the pilot in command, indicated that the aircraft was to proceed from Sydney (Kingsford-Smith) Airport to Norfolk Island, with an intermediate landing at Lord Howe Island to refuel. The flight was to be conducted in accordance with IFR procedures, with a departure time from Sydney of 0900. The aircraft, which was carrying 21 passengers, was crewed by two pilots, a supernumerary pilot and a flight attendant. Preparations for departure were completed shortly before 0900, and the aircraft was cleared to taxi for runway 16 via taxiway Bravo Three. The pilot in command occupied the left control position. The co-pilot was the handling pilot for the departure. The aircraft was cleared for takeoff at 0907:53. The crew subsequently reported to the investigation team that all engine indications were normal during the take-off roll and that the aircraft was flown off the runway at 81 kts. During the initial climb, at approximately 200 ft, with flaps up and the landing gear retracting, the crew heard a series of popping sounds above the engine noise. Almost immediately, the aircraft began to yaw left and at 0909:04 the pilot in command advised the TWR that the aircraft had a problem. The co-pilot determined that the left engine was malfunctioning. The crew subsequently recalled that the aircraft speed at this time had increased to at least 100 kts. The pilot in command, having verified that the left engine was malfunctioning, closed the left throttle and initiated propeller feathering action. During this period, full power (48 inches Hg and 2,700 RPM) was maintained on the right engine. However, the airspeed began to decay. The handling pilot reported that he had attempted to maintain 81 KIAS but was unable to do so. The aircraft diverged to the left of the runway centreline. The co-pilot and the supernumerary pilot subsequently reported that almost full right aileron had been used to control the aircraft. They could not recall the skid-ball indication. The copilot reported that he had full right rudder or near full right rudder applied. When he first became aware of the engine malfunction, the pilot in command assessed that, although a landing back on the runway may have been possible, the aircraft was capable of climbing safely on one engine. However, when he determined that the aircraft was not climbing, and that the airspeed had reduced below 81 kts, the pilot in command took control, and at 0909:38 advised the TWR that he was ditching the aircraft. He manoeuvred the aircraft as close as possible to the southern end of the partially constructed runway 16L. The aircraft was ditched approximately 46 seconds after the pilot in command first advised the TWR of the problem. The four crew and 21 passengers successfully evacuated the aircraft before it sank. They were taken on board pleasure craft and transferred to shore. After initial assessment, they were transported to various hospitals. All were discharged by 1430 that afternoon, with the exception of the flight attendant, who had suffered serious injuries.
Probable cause:
The following factors were considered significant in the accident sequence.
1. Compliance with the correct performance charts would have precluded the flight.
2. Clear and unambiguous presentation of CAA EROPs documentation should have precluded the flight.
3. The aircraft weight at takeoff exceeded the MTOW, the extent of which was unknown to the crew.
4. An engine malfunction and resultant loss of performance occurred soon after takeoff.
5. The operations manual take-off safety speed used by the crew was inappropriate for the overloaded condition of the aircraft.
6. The available single-engine aircraft performance was degraded when the co-pilot mishandled the aircraft controls.
7. The pilot in command delayed taking over control of the aircraft until the only remaining option was to conduct a controlled ditching.
8. There were organisational deficiencies in the management and operation of the DC-3 involving both Groupair and SPA.
9. There were organisational deficiencies in the safety regulation of both Groupair and SPA by the CAA district offices at Moorabbin and Bankstown.
10. There were organisational deficiencies relating to safety regulation of EROPS by the CAA.
Final Report:

Crash of a Britten-Norman BN-2A-21 Islander in Weipa: 6 killed

Date & Time: Mar 21, 1994 at 1754 LT
Type of aircraft:
Registration:
VH-JUU
Flight Phase:
Survivors:
No
Schedule:
Weipa - Aurukun
MSN:
632
YOM:
1971
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
6
Captain / Total flying hours:
321
Captain / Total hours on type:
6.00
Circumstances:
On the day before the accident, the aircraft flew from Aurukun to Weipa with the chief pilot occupying the left pilot seat and the pilot involved in the accident occupying the right pilot seat. At Weipa the chief pilot left the aircraft, instructing the other pilot to fly some practice circuits before returning the aircraft to Aurukun. Before commencing the circuits and the return flight to Aurukun, the aircraft's two main tanks each contained 100 L of fuel and the two wing tip tanks each contained about 90 L of fuel. On the day of the accident the pilot added 200 L of fuel at Aurukun to the aircraft's tanks and then flew the aircraft and the passengers to Weipa. About 50 minutes before sunset, the aircraft taxied for departure from runway 30 for the 25-minute return flight to Aurukun. When the aircraft was about 300 ft above ground level after takeoff, a witness reported that all engine sounds stopped and that the aircraft attitude changed from a nose-high climb to a more level attitude. A short time later, the noise of engine power surging was heard. The aircraft rolled left and entered a spiral descent. It struck level ground some 350 m beyond the departure end of runway 30 and 175 m to the left of the extended centreline. All six occupants were killed.
Probable cause:
Significant factors:
- The pilot mismanaged the aircraft fuel system.
- Both engines suffered a total power loss due to fuel starvation.
- The right engine regained power probably as a result of a change in aircraft attitude.
- The pilot lost control of the aircraft.
- Recovery was not possible in the height available.
Final Report:

Crash of a Swearingen SA226AT Merlin IVA in Tamworth: 1 killed

Date & Time: Mar 9, 1994 at 1734 LT
Operator:
Registration:
VH-SWP
Flight Type:
Survivors:
No
Schedule:
Inverell – Glen Innes – Armidale – Tamworth – Sydney
MSN:
AT-033
YOM:
1975
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
2782
Captain / Total hours on type:
335.00
Circumstances:
VH-SWP was operating on a standard company flight plan for the route Bankstown-Tamworth-Armidale-Glen Innes-Inverell and return, and the flight plan indicated the flight would be conducted in accordance with IFR procedures. The classification of the flight was shown as non-scheduled commercial air transport although the aircraft was operating to a company schedule, and departure and flight times for each route segment were indicated on the flight plan. The aircraft departed Bankstown at about 0640 and proceeded as planned to Inverell where the pilot rested until his departure that afternoon for the return journey. The schedule required an Armidale departure at 1721. At 1723 the pilot reported to Sydney Flight Service that he was departing Armidale for Tamworth. The planned time for the flight was 17 minutes. Although the flight-planned altitude for this sector was 6,000 ft, the pilot was unable to climb immediately because a slower aircraft, which had departed Armidale for Tamworth two minutes earlier, was climbing to that altitude. In addition, there was opposite direction traffic at 7,000 ft. The next most suitable altitude was 8,000 ft, but separation from the other two aircraft, which were also IFR, had to be established by the pilot before further climb was possible. The published IFR lowest safe altitude for the route was 5,400 ft. The pilot subsequently elected to remain at 4,500 ft in visual meteorological conditions (VMC) and at 1727 requested an airways clearance from Tamworth Tower. A clearance was issued by ATC to the pilot to track direct to Tamworth at 4,500 ft visually. At about 1732 the pilot requested a descent clearance. He was cleared to make a visual approach with a clearance limit of 5 NM by distance measuring equipment (DME) from Tamworth, and was requested to report at 8 DME from Tamworth. The pilot acknowledged the instructions and reported leaving 4,500 ft on descent. Transmissions from ATC to the pilot less than two minutes later were not answered. The aircraft was not being monitored on radar by ATC, nor was this a requirement. At about 1740, reports were received by the police and ATC of an explosion and possible aircraft accident near the mountain range 8 NM north-east of Tamworth Airport. The aircraft wreckage was discovered at about 2115 by searchers on the mountain range.Soon after the aircraft was reported missing, a search aircraft pilot, who had extensive local flying experience, reported to ATC that the top of the range (where the accident occurred) was obscured by cloud, and that there was very low cloud in the valley nearby.
Probable cause:
The following findings were reported:
- The pilot was making a visual approach in weather conditions unsuitable for such an approach.
- The pilot had not flown this route before.
- The aircraft was flown below the lowest safe altitude in conditions of poor visibility.

Crash of a Rockwell Grand Commander 690 off Sydney: 1 killed

Date & Time: Jan 14, 1994 at 0114 LT
Registration:
VH-BSS
Flight Type:
Survivors:
No
Schedule:
Canberra - Sydney
MSN:
690-11044
YOM:
1972
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
1800
Captain / Total hours on type:
50.00
Aircraft flight hours:
7975
Circumstances:
On 14 January 1994 at 0114, Aero Commander 690 aircraft VH-BSS struck the sea while being radar vectored to intercept the Instrument Landing System approach to runway 34 at Sydney (Kingsford-Smith) Airport, NSW. The last recorded position of the aircraft was about 10 miles to the south-east of the airport. At the time of the accident the aircraft was being operated as a cargo charter flight from Canberra to Sydney in accordance with the Instrument Flight Rules. The body of the pilot who was the sole occupant of the aircraft was never recovered. Although wreckage identified as part of the aircraft was located on the seabed shortly after the accident, salvage action was not initially undertaken. This decision was taken after consideration of the known circumstances of the occurrence and of the costs of salvage versus the potential safety benefit that might be gained from examination of the wreckage. About 18 months after the accident, the wing and tail sections of the aircraft were recovered from the sea by fishermen. As a result, a detailed examination of that wreckage was carried out to assess the validity of the Bureau’s original analysis that the airworthiness of the aircraft was unlikely to have been a factor in this accident. No evidence was found of any defect which may have affected the normal operation of the aircraft. The aircraft descended below the altitude it had been cleared to by air traffic control. From the evidence available it was determined that the circumstances of this accident were consistent with controlled flight into the sea.
Probable cause:
Findings
1. The pilot held a valid pilot licence, endorsed for Aero Commander 690 aircraft.
2. The pilot held a valid multi-engine command instrument rating.
3. There was no evidence found to indicate that the performance of the pilot was adversely affected by any physiological or psychological condition.
4. The aircraft was airworthy for the intended flight, despite the existence of minor anomalies in maintenance and serviceability of aircraft systems.
5. The aircraft carried fuel sufficient for the flight.
6. The weight and balance of the aircraft were estimated to have been within the normal limits.
7. Recorded radio communications relevant to the operation of the aircraft were normal.
8. Relevant ground-based aids to navigation were serviceable.
9. At the time of impact the aircraft was capable of normal flight.
10. The aircraft was fitted with an altitude alerting system.
11. The aircraft was not fitted with a ground proximity warning system.
12. The aircraft was equipped with a transponder which provided aircraft altitude information to be displayed on Air Traffic Control radar equipment.
3.2 Significant factors
1. The pilot was relatively inexperienced in single-pilot Instrument Flight Rules operations on the type of aircraft being flown.
2. The aircraft was being descended over the sea in dark-night conditions.
3. The workload of the pilot was significantly increased by his adoption of a steep descent profile at high speed, during a phase of flight which required multiple tasks to be completed in a limited time prior to landing. Radio communications with another company aircraft during that critical phase of flight added to that workload.
4. The pilot probably lost awareness of the vertical position of the aircraft as a result of distraction by other tasks.
5. The aircraft was inadvertently descended below the altitude authorized by Air Traffic Control.
6. The secondary surveillance radar system in operation at the time provided an aircraft altitude readout which was only updated on every sixth sweep of the radar display.
7. The approach controller did not notice a gross change of aircraft altitude shortly after a normal radio communication with the pilot.
Final Report:

Crash of a De Havilland DH.104 Dove 5 in Melbourne

Date & Time: Dec 3, 1993 at 2037 LT
Type of aircraft:
Operator:
Registration:
VH-DHD
Flight Phase:
Survivors:
Yes
Site:
Schedule:
Melbourne - Melbourne
MSN:
04104
YOM:
1948
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
18154
Captain / Total hours on type:
1500.00
Aircraft flight hours:
21259
Circumstances:
The pilot had planned to conduct a night charter flight over Melbourne and Port Phillip Bay, starting from and returning to Essendon Airport. Dinner was to be served in flight. The pilot gave a safety briefing to the passengers before starting the engines. He completed engine runups and pre-takeoff checks, including selecting 20° of flap. At 2036 ESuT, in daylight, the pilot initiated takeoff on runway 17 using standard take-off power setting of 7.5 lb/in2 of boost and 3,000 RPM. Wind conditions were light and variable, visibility was about 10 km and the temperature was 19°C. The aircraft became airborne and, just as it achieved the take-off safety speed of 84 kts, at a height not above 50 ft, the right engine lost power. The aircraft yawed right. The pilot reported to the investigation team that he briefly noticed a reading of 3 lb of boost on the MAP gauge and assessed the problem as a possible partial right engine failure. He then selected the landing gear up but it did not retract. He cycled the landing gear selector once and the gear then retracted. By this time several seconds had elapsed and the airspeed had decayed to 76 kts. The pilot then assessed the airspeed as too low to retract the flaps and left them at 20°. The airspeed continued to decay until VMCA, 72 kts, was reached. When indicated airspeed had further decayed to 68 kts, the pilot reduced power on the left engine to avoid an uncontrollable roll to the right. He was able to maintain wings level and attempted to track the aircraft toward a street but was unable to maintain height. The aircraft collided with powerlines and then struck the roofs of several houses before coming to rest, on its left side, against the front wall of a house. About one minute had elapsed from initiation of takeoff until the accident. The pilot and all but one of the passengers remained conscious throughout the accident sequence. All occupants were evacuated, some without assistance and others with the assistance of the pilot, other passengers, emergency services personnel or bystanders.
Probable cause:
The following factors were reported:
- The right engine fuel control unit fuel pump failed causing the engine to fail at a critical phase of flight.
- Maintenance inspections did not detect the abnormal wear on the thrust face of the right engine fuel control unit fuel pump.
- The landing gear did not retract on the first attempt and aircraft performance decayed while the pilot resolved this problem.
- The pilot was probably forced to abandon the emergency procedures to concentrate on maintaining control of the aircraft.
- The aircraft was unable to maintain altitude and airspeed with the right propeller windmilling and 20° of flap.
- The investigation identified organisational factors concerning deficiencies in the manuals and procedures available to, and used by, the operator for the operation and maintenance of the accident aircraft.
Final Report:

Crash of a Piper PA-31-350 Navajo Chieftain in Launceston: 6 killed

Date & Time: Sep 17, 1993 at 1943 LT
Operator:
Registration:
VH-WGI
Survivors:
Yes
Schedule:
Melbourne - Launceston
MSN:
31-7305075
YOM:
1973
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
6
Captain / Total flying hours:
701
Captain / Total hours on type:
3.00
Aircraft flight hours:
8712
Circumstances:
Members of a football club had planned to visit Launceston, travelling by light aircraft. Three aircraft were needed to carry the group, with all passengers and pilots contributing to the cost of the aircraft hire. One of the club members, who was a pilot, organised the required aircraft and additional pilots for departure from Moorabbin Airport on the afternoon of 17 September 1993. The operator from whom the aircraft were hired, who also employed the organising pilot as an instructor, arranged for one Piper PA-23 (VH-PAC), a Piper PA-31-310 (VH-NOS) and a Piper PA-31-350 (VH-WGI) to be available for the trip, with the organising pilot to fly VH-WGI. On the day of the flight the pilot of VH-WGI carried out pre-flight inspections, obtained the weather forecasts and submitted flight plans for all three aircraft. The flight plans for the two PA-31 aircraft were for flights operated in accordance with IFR procedures. The PA-23 was to operate in accordance with VFR procedures. The TAF for Launceston predicted 2 octas of stratocumulus cloud, base 2,000 ft and 3 octas of stratocumulus cloud, base 3,500 ft. The flight plan for VH-WGI (see fig. 2) indicated that the aircraft would track Moorabbin Wonthaggi-Bass-Launceston and cruise at an altitude of 9,000 ft. A cruise TAS of 160 kts, total plan flight time of 90 minutes, endurance 155 minutes and Type of Operation 'G' (private category flight) were specified. No alternate aerodrome was nominated and none was required. The estimated time of departure was 1730. The flight plan was submitted to the CAA by facsimile at 1529. Last light at Launceston was 1919. VH-WGI departed Moorabbin at 1817 and climbed to an en-route cruise altitude of 9,000 ft. The pilot was required to report at Wonthaggi but passed this position at 1832 without reporting. Melbourne ATC tried unsuccessfully to contact the pilot because of this missed report. Later, the Melbourne radar controller noticed the aircraft deviating left of track but was unable to make contact. Communications were re-established at 1858 when the pilot called Melbourne FS saying he had experienced a radio problem. By this time the aircraft heading had been corrected to regain track. At 1927 the pilot called Launceston Tower and was cleared for a DME arrival along the inbound track of the Launceston VOR 325 radial. The Launceston ATIS indicated 2 octas of cloud at 800 ft, QNH 1,012 hPa, wind 320° at 5-10 kts, temperature +10° and runway 32 in use. At 1930 the ADC advised the pilot that the 2 octas of cloud were clear of the inbound track, but that there was some lower cloud forming just north of the field, possibly on track. He informed the pilot that there was a chance he might not be visual by the VOR, in which case he would need to perform an ILS approach via the Nile locator beacon. The ADC contacted the airport meteorological observer at 1933, inquiring as to what the 1930 searchlight check of cloud height had revealed. He was told the observation indicated 7 octas of cloud at about 800 ft. At 1935.52 (time in hours, minutes and seconds) the ADC asked the pilot for his DME (distance) and level. The pilot responded that he was at 12 DME and 3,300 ft. The ADC told the pilot that conditions were deteriorating with probably 4 octas at 800 ft at the field. He then told the pilot he would hopefully get a break in the cloud, but then restated that if he was not visual by the VOR to make a missed approach, track to Nile and climb to 3,000 ft. At 1939.45 the pilot was again asked for his DME and level. He indicated that he was at 1,450 ft and 2-3 DME. He then also confirmed that he was still in IMC. There were three other aircraft inbound for Launceston and the ADC made an all-stations broadcast that conditions were deteriorating at Launceston, with 4 octas at 800 ft, and to expect an ILS approach. At 1940.56 the pilot stated that he was overhead the field, but did not have it sighted and was going around. At 1941.07 the pilot reported that he had the airfield in sight and at 1941.16 that he was positioned above the final approach for runway 32. Fifteen seconds later the pilot reported that he was opposite the tower and was advised by the ADC that he was cleared for a visual approach, or a missed approach to Nile as preferred. The pilot indicated he would take the visual approach and was then told to manoeuvre as preferred for runway 32. This was acknowledged at 1941.48. No further communications were received from the pilot. The ADC made a broadcast to two other inbound aircraft at 1942.32, advising that VH-WGI was in the circuit ahead of them, that it had become visual about half a mile south of the VOR, that it was manoeuvring for a visual approach and was just in and out of the base of the cloud. After the pilot of VH-WGI reported over the field, and the aircraft first appeared out of cloud, witnesses observed it track to about the south-east end of the aerodrome at a height of about 500-800 ft. It then turned left to track north-west on the north-east side of the main runway and approximately over the grass runway. The aircraft was seen to be travelling at high speed, and passing through small areas of cloud. North of the main terminal building a left turn was initiated onto a close downwind leg for runway 32. The aircraft appeared to descend while on this leg. As the base turn was started, at a height estimated as 300-500 ft, the aircraft briefly went through cloud. Some of the witnesses reported that the engine noise from the aircraft during the approach was fairly loud, suggestive of a high power setting. Late on a left base leg the aircraft was observed to be in a steep left bank, probably in the order of 60°, at a height of about 200 ft. It then descended rapidly and struck a powerline with the right wing, approximately 28 ft AGL, resulting in an airport electrical power failure at 1943.02. Almost simultaneously the left wing struck bushes. A short distance beyond the powerlines the aircraft struck the ground and slid to a stop. A fierce fire broke out immediately. Airport fire services responded to the accident and the fire was quickly extinguished. Six of the occupants received fatal injuries and the others, including the pilot, were seriously injured.
Probable cause:
The following findings were reported:
1. The actual weather at Launceston at the time of arrival of VH-WGI was significantly worse than forecast.
2. The pilot did not have the required recent experience to conduct either an IFR flight or an ILS approach. The operator's procedures did not detect this deficiency.
3. The pilot's inexperience and limited endorsement training did not adequately prepare him for IFR flight in the conditions encountered.
4. The CAA did not specify adequate endorsement training or minimum endorsement time requirements for aircraft of the class of the PA-31-350, particularly in regard to the endorsement of inexperienced pilots.
5. An absence of significant decision-making training requirements contributed to the poor decision-making action by the pilot who decided to continue with a visual circling approach at Launceston in conditions that were unsuitable for such an approach.
6. As a consequence of continuing the approach, the pilot subjected himself to an overwhelming workload. This was due to a combination of adverse weather conditions, his lack of training and experience in IFR approach procedures on the type, and a misinterpretation of (or non-compliance with) the AIP/DAP-IAL instructions, a combination which appears to have influenced the pilot to fly a close-in, descending circuit at low altitude. The carriage of alcohol-affected passengers may have also added to the level of difficulty.
7. Because of workload, and possibly also due to distractions, the pilot inadvertently allowed the aircraft to enter a rapid descent at a critical stage of the approach, at an altitude from which recovery could not be effected.
Final Report:

Crash of a Piper PA-31-310 Navajo near Brisbane: 1 killed

Date & Time: Jul 20, 1993 at 1546 LT
Type of aircraft:
Operator:
Registration:
VH-UFO
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Brisbane – Caboolture
MSN:
31-7712060
YOM:
1977
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
531
Captain / Total hours on type:
35.00
Circumstances:
The aircraft, with only the pilot on board, was being flown from Archerfield to Caboolture via the light aircraft lane to the west of Brisbane in company with another aircraft. About five minutes after departing Archerfield, the pilot radioed that he was experiencing problems with both engines and that he was in an emergency situation. The pilot of the other aircraft advised him that there were suitable forced landing areas in and around a nearby golf course. However, the aircraft continued and slowly lost altitude before rolling inverted and diving steeply into the ground. Ground witnesses reported hearing loud backfiring and fluctuating engine RPM from the aircraft. These sounds were accompanied by erratic rolling and yawing of the aircraft before it rolled to the left and inverted. The right wing was severed outboard of the engine as the aircraft impacted a large tree before crashing onto a road.
Probable cause:
Wreckage examination revealed that the fuel selectors for both engines were set at the auxiliary tank positions, causing fuel for each engine to be drawn from the corresponding auxiliary tank in each wing. It was established that the aircraft had been refuelled to full main tanks prior to the flight. Further, the pilot had advised in a telephone conversation with an engineer before the flight that the contents of both auxiliary tanks was 60 litres or less. All fuel tanks except the left auxiliary tank were ruptured during the impact sequence. About one litre of fuel was recovered from this
tank. Examination of the aircraft engines indicated that the right engine was under power at impact while the left engine was not. The mechanical condition of the engines indicated that they were capable of normal operation.
The following factors are considered relevant to the development of the accident:
- The pilot did not use a written checklist.
- The pilot operated the aircraft with the auxiliary tanks selected when the fuel contents of these tanks was low.
- The pilot failed to conduct a forced landing.
Final Report: